Examination Application For Board Certification as a Specialist in Gerontological Nutrition (CSG)

Transcription

1 Instructions: Read and follow carefully all specific instructions in the application booklet when completing the application form. After completing this application, return it with your examination fee to: Commission on Dietetic Registration, 120 South Riverside Plaza, Suite 2000, Chicago, IL Attention: Specialty Certification. Part A- Candidate Information Registration Number*: First and Credentials: Street Address: City, State and Zip Code: Country (if not United States): Day-Time Phone Number: Address: Indicate Highest Degree Completed: bachelors masters doctorate Indicate which examination window you are applying (month/year): *used for identification purposes only

2 Part B- Specialty Examination Fee Payment Amount enclosed*: Special offer code (if applicable): I have enclosed check (please include RD number on your check) Discount code, if applicable: I wish to pay by credit card: Visa MasterCard Discover American Express Name as it appears on your credit card: Credit card number: Credit card expiration date: Signature: *Please note there is different examination fees associated with different postmark deadline dates. For examination fee schedule, please visit CDR s website or specialists@eatright.org. First application postmark deadline= $350 Second application postmark deadline= $375 Third application postmark deadline= $400

3 Part C-1- Verification of Specialty Practice Hours Instructions: Complete one Part C-1 form for each position that you have held in the specialty area (within the past five years) until the required hours are documented. Future dates/hours that have not been worked yet cannot be documented. It is not necessary to document more than the required specialty practice hours. Further information is in the application booklet. Specialty practice hour requirement: 2,000 hours Name of organization: Address: Indicate position title: Indicate date range of specialty practice hours (mm/dd/yyyy to mm/dd/yyyy): Indicate number of specialty hours worked within the date range above: Are you currently employed in this position? Briefly describe your gerontological nutrition related job duties: Authorized Signature: This section is to be completed by the authorized individual, such as employer, supervisor, or human resources or if a consultant the person or doctor who refers clients to you. First and Last Name of authorized individual: Credentials: Current position title of authorized individual: Daytime phone number of authorized individual: I verify that the candidate indicated on this form is or was employed or served as an employee/contractor for the organization that I represent. I have reviewed the specialty practice areas as defined below and verify that the applicant s practice experience was related to gerontological nutrition. In the position listed I have/had the opportunity to directly observe the applicant s job responsibilities. Authorized signature: Date: I am a consultant, and instead of the signature of the authorized individual, I have enclosed tax/income documentation and/or pay records, receipt, letter from accountant, and brochure/information about my business to document all of the specialty employment hours listed. Gerontological Nutrition Dietitian Definition: Gerontological nutrition dietitians design, implement and manage safe and effective nutrition strategies to promote quality of life and health for older adults. They work directly with older adults to provide optimal nutrition and food sources and information in a variety of settings (such as, hospitals, long term care, assisted living, home health care, community-based nutrition programs, food service industry, correctional facilities, governmental programs, related industries), or indirectly as documented by management, education or research practice linked specifically to gerontological nutrition.

4 Part C-2- Verification of Professional Experience Instructions: For each professional experience, indicate the number of specialty hours documented. Professional experiences must be gerontological nutrition related and completed within the past five years (from the application postmark deadline). The amount of hours and documentation requirements are listed in the application booklet. Note substitution of the required 2,000 hours cannot exceed 800 hours, even when combined with an education substitution. If you do not have any specialty hours from professional experiences or if you have all of the required hours through work experience, then please skip this section. Specialty Work Experience Number of Specialty Hours Documented Primary author of an article in a peer-reviewed scientific publication (20 hours maximum per article) Co-author of an article in a peer-reviewed scientific publication (10 hours maximum per article) Author of a gerontological nutrition textbook/manual (100 hours maximum per textbook/manual) Author of a chapter in a gerontological nutrition textbook/manual (25 hours maximum per chapter) Presenter at a peer-reviewed national, state and/or regional scientific conference (15 hours maximum per presentation) Research-sole or principal investigator (20 hours maximum per research activity) Research- co-investigator (10 hours maximum per research activity) Required documentation for each activity enclosed*

5 Part C-3- Substitution of Education Instructions: Education from an US-accredited college or university (or foreign equivalent) will be allowed to substitute for some of the required experience according to the following chart (any combinations can substitute up to the maximum). Degree Masters degree in nutrition, health or education Doctorate degree in nutrition, health or education Fellowship in specialty area, post RD Hours Substituted 300 hours 400 hours 500 hours Note: graduate degrees and fellowship hours, even if combined with another degree or specialty professional experience hours, cannot substitute for more than 800 hours (40%) of the required 2,000 hours of specialty practice experience. For more information and instructions, refer to the application booklet. If you are not using an educational degree to substitute for a portion of your specialty practice hours or if you have all of your required practice hours through employment and/or professional experiences, then please skip this section. Name of College/University: Address: City, State and Zip Code: Type of Degree: Date degree completed (mm/dd/yyyy): Hours substituted: Official transcript enclosed

6 Part D- Candidate Acknowledgement Instructions: Read the verification statement and then sign and date the application. I certify that the information and documentation presented in this application are accurate to the best of my knowledge. CDR has the right to verify the information presented. I understand that this application does not guarantee any rights or privileges. Print your first and last name: Signature of applicant: Date: Part E- Final Checklist Part A- Candidate Information: All information is complete Part B- Specialty Examination Fee Payment enclosed If paying by check, RD number is written on check If paying credit card, information is complete Part C-1- Verification of Employment Required work hours documented within the past five years Part C-2- Verification of Professional Experience Documented dates for professional experiences within the past five years Required documentation enclosed for professional experiences Part C-3- Education Substitution Official transcript enclosed Minimum total of 2,000 specialty hours documented Part D- Candidate Acknowledgement I have read and signed the acknowledgement statement Total hours documented: Total hours documented: Total hours documented